ADVANCED AESTHETICS, P.C.
PLASTIC SURGERY CENTER
FINANCIAL POLICY
COSMETIC CONSULTS:
Providing your visit is strictly cosmetic in nature, meaning there are no third parties involved such as insurance
carriers, attorneys, etc., your visit is complimentary. If during your complimentary or follow-up visit your
consult becomes an insurance issue then the visit is no longer complimentary. We are required to follow
your insurance company’s guidelines and the visit is billable with appropriate office visit fees and co-pays
collected at time of service. If your policy requires a referral for office visits, you may be asked to
reschedule another appointment to enable you to obtain your referral and you will be responsible for the
charge for the initial office visit. Please initial that you have read and understood this paragraph _______
INSURANCE VISITS:
If your visit is covered by insurance we are required to follow their specific guidelines as it applies to your
policy and benefits for both your primary and secondary insurance. Some insurance companies require a
referral before we are allowed to see you as a patient. It is your responsibility to determine if a referral(s) is/are
required and have it in hand at the time of your visit. If an office visit fee is required by your insurance carrier it
will be collected as you sign in. If we are not a participating provider, payment is due at the time of service
unless prior arrangements have been made. Please see our Insurance Coordinator if you are unsure of our
provider status with your carrier.
FILING INSURANCE:
As a courtesy, we will file to both your primary and secondary carriers that we are participating providers.
Please be advised that we DO NOT file to automobile carriers, attorneys, home owner policies or accept letters
of guarantee or other promises to pay when claims are settled.
NO INSURANCE:
If you have no insurance, payment is due at the time of service.
FINANCIAL ARRANGEMENTS:
We accept Cash, Personal Checks, Travelers Cheques, Master Card, Visa, American Express and Discover.
Additionally, for our Cosmetic patients we also accept CareCredit credit cards (minimum charge is $2,000). A
service charge of $25 will be applied to returned checks.
PATIENT’S RESPONSIBILITY:
Fees not paid within ninety (90) days by your carrier will be your responsibility. We currently use an outside
Collection Agency to assist us in collecting balances due by our patients that are over 90 days old. It is
important that you keep up with your statements and account balances and discuss any problems you may have
satisfying your account with our Insurance Coordinator. These outstanding balances will be forwarded to credit
reporting bureaus and you could be held responsible for expenses incurred in the collection of any past due
balances. NOTE: We encourage you to contact your carrier and follow up on payment to assure your expenses
are met.
ACKNOWLEDGEMENT:
I HAVE READ THE ABOVE AND UNDERSTAND THE FINANCIAL POLICY OF ADVANCED
AESTHETICS, P.C.
Patient’s Signature: _______________________________ Date: ________________________
Print Name: ___________________________________
Responsible Party’s Signature:_______________________________ Date: ____________________
Print Name: ___________________________________